Test 3 Flashcards by Sydney Coopland

Whats Is included in the Upper GI?

Esophagus
Stomach
First part of your small intestine (the duodenum)

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More susceptible to the adverse effects of drugs, may develop confusion, more susceptible to the effects of dehydration
Food borne illnesses
Inflammation and infections – may manifest other problems like leukemia and vitamin deficiencies, - immunocompromised individuals are susceptible to oral infections, also people taking corticosteroids.
Include gingivitis, oral candidiasis, herpes, apthous (canker sore), parotitis (inflammation of patotid gland), stomatitis, inflammation of mouth
Oral cancers = risk increases with tobacco, alcohol, HPV, leukoplakia ( precancerous conditions of the oral cavity), family history, overexposure to sun ultraviolet rays.
Lips with the sun and pipe smoking
Tongue – syphilis, tobacco, alcohol – see thickened areas, pain, slurred speech, dysphagia, toothaches and later signs of spread such as ear aches.
Oral cavity – from poor hygiene, tobacco – including chewing tobacco, alcohol, chronic irritation (ill fitting prosthesis) HPV – leukoplakia, ulcers, sore spots, dysphagia, difficulty chewing a,d later speaking

Age related problems

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Cephalic (nervous)
Gastric (hormonal and nervous)
Intestinal (hormonal)

Gastric Secretion Phases

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________ (nervous)
Secretion of hydrogen chloride (HCl), pepsinogen, mucus

Cephalic

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__________ (hormonal and nervous)
Release of gastric hormone from antrum to stimulate gastric secretions and motility

Gastric

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_________ (hormonal)
Acidic chyme (pH <2): Release of secretin, gastric inhibitory polypeptide, cholecystokinin
Chyme (pH >3): Release of duodenal gastrin

Intestinal

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Mouth: Periodontal disease, taste buds decrease, xerostomia, dysphagia
Esophagus: Decreased tone and motility
Abdominal wall: Thinner, decreased receptors
Stomach, small intestine, liver, gallbladder, and pancreas: Decreased synthesis and secretions
Large intestine, anus, and rectum: Decreased tone, motility, and transit time

Age related changes

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Serum bilirubin (total, direct and indirect)
Urinary bilirubin
Serum protein levels (albumin, globulin, total protein)
A-fetaprotein (hepatic tumour marker)
Ammonia
Prothrombin
Vitamin K
Alkaline phosphatase (ALP)
Aspartate antinotransferase (AST)
Alanine aminotransferase (ALT)
Glutamyl transpeptidase (GGT
Serum Cholesterol

Upper GI diagnostics

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Increased
proportion of fat cells.
Complex interactions

Obesity

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BMI of 30–34.9 kg/m2 is class 1 obesity
BMI of 35–39.9 kg/m2 is class 2 obesity
BMI of more than 40 kg/m2 is class 3 obesity (morbidly obese)

BMI

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Less than 0.80 is optimal

WHR (wait to hip ratio)

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Cardiovascular conditions
Respiratory conditions
Diabetes mellitus
Musculoskeletal conditions
Gastrointestinal and liver conditions
Cancer
Psychosocial issues

Health risks associated w obesity

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18.5 to 24.9

Healthy BMI

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Collection of risk factors that increase an individual’s chance of developing cardiovascular disease and diabetes mellitus

Metabolic syndrome

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Diagnosed if the following criteria is present:

Metabolic syndrome

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Obesity
Reduced skin integrity
Inadequate breathing pattern
Reduced self-esteem
Reduced physical mobility
Disrupted body image

Nursing diagnosis

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Works by blocking fat breakdown and absorption in the intestine
Undigested fat is excreted in feces
Adverse effects

Orlistat (medication)

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Injectable medication that works by blocking glucagon-like peptide
Normally used for treatment of type 2 diabetes
Adverse effects

Liraglutide (medication)

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Combination of low-dose naltrexone and bupropion
Work on two separate areas of the brain involved in controlling hunger
Adverse effects

Naltrexone HCL/bupropion HCL (medication)

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is used to treat morbid obesity. Currently it is the only treatment found to have a successful and lasting impact for sustained weight loss.

Bariatric surgery

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Stringent criteria for consideration for surgery
Three categories: restrictive, malabsorptive, or a combination of both

Bariatric surgery

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The number of __________ with obesity has risen.
Obesity is more common in women than in men.
Decreased energy expenditure and loss of muscle mass are important contributors.
Exacerbates age-related problems
The same therapeutic approaches apply to older adults with obesity.

older persons

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Most common manifestations of gastrointestinal (GI) diseases

nausea and vomiting

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CVSMetabolic
CNS
Poison
Drugs
Psychological
Pregnancy
Allergies
GI Disorders

Causes of nausea and vomiting

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nausea, vomiting, diarrhea, colicky pain

FOOD BORNE ILLNESS

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causes hemorrhagic colitis and kidney failure
Abdominal pain and diarrhea lasts 2 – 8 days
Can lead to systemic problems
Treatment is supportive
No antidiarrheal agents

ECOLI –0157:H7

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They may be specific mouth diseases, or they may occur in the presence of some systemic diseases such as leukemia or vitamin deficiency.

Oral Inflammations and Infections

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When ____________ are present, they can severely impair the ingestion of food and fluids.

Oral Inflammations and Infections

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____________ may occur on the lips or anywhere within the mouth (e.g., tongue, floor of the mouth, buccal mucosa, hard palate, soft palate, pharyngeal walls, tonsils).
It was estimated that in 2017, 1250 persons would die from this disease.

Oral (or oropharyngeal) cancer

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__________ sometimes:
NPO
Nasogastric tube
Clear fluids
Crackers, dry toast
High carbs, low fat
Adjunct therapies

BESIDES MEDICATIONS

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Metoclopramide, Haloperidol, Domperidone

Dopamine antagonists

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Dimenhydrinate, Diphenhydramine

Antihistamines

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Ondansetron

Serotonin antagonists

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Scopolamine

Antimuscarinics

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Prochlorperazine, Promethazine

Phenothiazines

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Clonazepam, diazepam, lorazepam

Benzos

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Nausea
Deficient fluid volume
Imbalanced nutrition: less than body requirements

vomiting

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Be comfortable with minimal or no nausea and vomiting.
Maintain body weight.
Have electrolyte levels within normal range.
Be able to maintain adequate intake of fluids and nutrients.
Maintain normal urine volume.

Expected outcomes

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More likely to have cardiac or renal insufficiency
Increased risk for life-threatening fluid/electrolyte imbalances
Increased susceptibility to CNS adverse effects of antiemetic medications

Nursing Management:Age-Related Considerations

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GERDHiatus Hernia
Esophageal diverticula
Achalasia
Esophageal structure and varices

Esophageal disorders

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Esophageal disorders ______:
Impaired Esophageal Motility, Defective Mucosal Defence, Delayed Gastric Emptying, LES dysfunction, Small intestine Reflux of Bile, Reflux of Gastric Contents

Causes

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Esophageal disorders ______:
Heartburn
Respiratory symptoms,
Otolaryng-ological symptoms,
Regurgitation
Early satiety
Bloating
N&V

Symptoms

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Esophageal disorders ______:
ESOPHAGIITIS, BARRETT’S ESOPHAGUS

Complications

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Esophageal disorders ______:
Antacids
Antisecretory gents
Cholinergic Drugs
H2 receptor blockers
PPI
Prokinetics

Treatment

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Cholinergic - Bethanechol

Increase LES pressure

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Prokinetics - Metoclopramide

Promotility

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Antacids – Maalox, Mylanta

Acid neutralizing

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H2 receptor blockers – Famotidine, Ranitidine
PPI – Esomeprazole, Omeprazole, Pantoprazole

Anti-secretory

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Alginic acid antacid - Gaviscon
Acid protective – Sucralfate

Cytoprotective

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Portion of the stomach herniates into the esophagus through an opening in the diaphragm.
Two types:
Sliding (most common)
Rolling (paraesophageal

hiatal hernia

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occurs when the upper part of the stomach pushes up into the chest through a small opening in the diaphragm, the muscle that separates the abdomen from the chest

hiatal hernia

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Structural Changes; Factors that increase intra-abdominal pressure; Age, Trauma, Poor nutrition, Forced Recumbant Position

Hiatal hernia causes

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Some are asymptomatic,
Similar symptoms as GERD,
Dysphagia,
Reflux and discomfort associated with position,
Nocturnal heartburn

Hiatal hernia symptoms

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GERD, Hemorrhage, Stenosis, Hernia ulcerations and strangulation, Regurgitation with tracheal aspiration.

Hiatal hernia complications

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Antacids
Antisecretory agents (H2R receptor blockers and PPIs

Hiatal hernia treatment

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Incidence increases with age.
Both are associated with weakening of the diaphragm, obesity, kyphosis, and use of corsets or other factors that increase intra-abdominal pressure.
First indications may include esophageal bleeding secondary to esophagitis or respiratory complications (e.g., aspiration pneumonia) related to aspiration of gastric contents.

GERD and Hiatal Hernia

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Antacids
H2R blockers
PPI’s

Antibiotics for Hpylori,
B 12

Gastritis treatment

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Drugs, Diet, Microorganisms, Environmental, Pathophysiological Conditions

Gastritis causes

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Acute gastritis – anorexia nausea, vomiting, epigastric tenderness and feeling of fullness,
Hemorrhaging
With chronic there can be cobalamin deficiency, anemia and neurological complications.

Gastritis symptoms

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Cobalamin deficiency, Anemia, gastric cancer if from H pylori

Gastritis complications

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Sac-like outpouchings of one or more layers of esophagus
Occur in three main areas
Zenker’s diverticulum
Most common location
Traction diverticulum
Near esophageal midpoint
Epiphrenic diverticulum
Above the LES

Esophageal Diverticuli

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Clinical Manifestations
Dysphagia
Regurgitation
Chronic cough
Aspiration
Weight loss

Esophageal Diverticula

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Diagnosis:
Barium Studies

Esophageal Diverticula

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Complications:
Malnutrition
Aspiration
Perforation

Esophageal Diverticula

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Peristalsis of lower two-thirds of esophagus absent
Impairment of neurons that innervate esophagus
Unopposed contraction of LES
LES pressure increases.
Incomplete relaxation of LES
Obstruction occurs at/near diaphragm
Food and fluid accumulate in lower esophagus
Result: dilation of lower esophagus

Achalasia

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Symptoms
Dysphagia (Most common symptom **)
Globus sensation
Substernal chest pain
During/after a meal
Halitosis
Inability to belch
GERD
Regurgitation
Weight loss

Achalasia

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Diagnostics:
Radiological studies
Manometric studies of the lower esophagus
Endoscopy

Achalasia

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Inflammation of gastric mucosa
One of most common problems affecting the stomach ***
Result of a breakdown in gastric mucosal barrier.
Tissue edema results.
Disruption of capillary walls.

Gastritis

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Dilated tortuous veins in lower portion of esophagus
Result of portal hypertension
Common complication of liver cirrhosis

Esophageal Varices

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Drug induced
Esophagus
Stomach and Duodenum
Systemic Diseases

Upper GI bleed causes

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DRUGS
Vasopressin
H2R blockers
Antacids
PPIs
Octreotides

Upper GI bleed treatment

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Endoscopy
Labs

Upper GI bleed diagnostics

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Melena
Hematemesis
Occult bleeding
Weakness, Dizziness
Epigastric pain, ABD Cramps, N&V
Sweating, Cool clammy skin
Fever, Tachypnea
Tachycardia
Orthostatic hypotension
Weak pulse
Decreased urine output
Agitation, restlessness

Upper GI bleed symptoms

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Decreased HCT
Decreased HBG
Guaiac +-stools, emesis or gastric.
Increased liver enzymes
Abnormal GI studies and scopes.

Upper GI bleed lab values

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Risk for decreased CO
Deficient fluid volume
Ineffective tissue perfusion
Anxiety

Upper GI bleed

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Peptic ulcer disease can effect ______ & _______

Gastric; Duodenal

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superficial, smooth
Antrum and body and fundus of stomach
Gastric secretions normal or decreased
Higher incidence with women
Peak age 50 – 60
Burning or gaseous pressure, cramping pressure
If a penetrating ulcer then pain 1 -2 hrs after a meal

Gastric

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Penetrating – bulb or deformity
Frist 1 -2 cm of duodenum
Gastric secretions increased
Men>women
Peak age 35 – 45
Pain 2- 4 hrs after meals
Pain is periodic and episodic
Sometimes N & V
Pain relief with antacids and food.

Duodenal

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Acute or chronic
Dehydration
Electrolyte disturbances
Malabsorption/malnutrition
Decreased fluid absorption
Increased fluid secretion
Motility disturbances (someone who has had a stroke, impacts bowels)

Diarrhea

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Demulcent
Anticholinergic
Antisecretory
Opioid
Probiotics

Diarrhea medications

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Increased problems w age / someone who is ___________
Anyone who is _____________ will be prone to bowel problems

immunocompromised

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_______ & ________ impacted
What are we looking for in the stool?
Blood, absorption, cancer screening, parasites, worms, stool fat (absorption stuff), serum levels of GI hormones (vasoactive changes in the bowels)
Scopes – diagnostic tool
Ultrasounds, CT scans, MRI, enemas, X ray (check for excess air/distension)

Iron & folate

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biggest thing is preventing dehydration & electrolyte imbalances

Diarrhea

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used for diarrhea, often. Connection to the brain & everything else.

Probiotics

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Pepto-Bismol, coats – protects against burning

Demulcent

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decrease intestinal secretions

Antisecretory

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chronic diarrhea, side effect is constipation

Opioids

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can help but can also cause due to flora change; C. diff is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon).

Antibiotics used

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Most cases of C. diff infection occur while you’re taking antibiotics or not long after you’ve finished taking antibiotics.
- Main medication used is _____; metal taste in the mouth (alters taste buds)

Flagyl

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Intake of poorly absorbable solutes
Maldigestion and Malabsorption
Mucosal damage
Pancreatic insufficiency
Intestinal enzyme deficiencies
Bile salt deficiencies
Decreased surface area.

Decreased fluid absorption

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Infectious
Drugs
Foods
Hormonal
Tumour

Increased fluid secretion

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IBS
Diabetic Enteropathy
Gastrectomy

Motility disturbances

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Motility disturbances
Increased fluid secretion
Decreased fluid absorption

are all causes of

Diarrhea

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A symptom
Frequent passage of loose, water stools

Diarrhea

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Traumatic
Neurological
Inflammatory
Functional
Pelvic flood dysfunction

Fecal incontinence

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Poor fluid intake
Medications
Lack of exercise
Mental health
Changes in routine
Chronic laxative use
Resisting the urge
Lack of fibre

Constipation

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Dehydration – know the signs (which we do lol)
Older people who are dehydrated – confusion, more tired
Kids eyes – sunken when dehydrated
Baby’s fontanels impacted
Increased HR – tachycardia
Skin turgor – decreased

Constipation

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IBS-C

constipation

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Used during straining to pass a hardened stool.
May cause serious problems with individuals who have heart failure, cerebral edema, hypertension and CAD
Causes increased intra-abdominal pressure and increased intrathoracic pressure which decreases venous return.
Temporary bradycardia, decreased cardiac output and a transient drop in arterial pressure.
Then when the patient relaxed there is a decreased in thoracic pressure and a sudden flow of blood flow to the heard which causes distension and in increase in heart rate.

Valsalva Manoeuvre

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Will increase the pressure – pushing
Not good for HF
Bradycardia, syncope (fainting)
Sudden flow that goes back to the heart – that is what people can’t handle

Valsalva Manoeuvre

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Poor fluid intake
Meds
Lack of exercise
Mental health
Changes in routine
Chronic laxative use
Resisting the urge
Lack of fiber

Constipation

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Goal is to prevent any further complications
How long has this been going on?
Nursing interventions can we do? Not what the physician is going to order. All kinds of things. ______, _______, _______, _______

Increase activity, fluids, fiber, educate

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Inflammation
Vascular
Gynaecological
Infectious
Other

Abdominal pain

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Signs and symptoms of colorectal cancer by location of primary lesion.

Pain related to different types of cancer areas

Acute Abdominal Pain in Colorectal Cancer

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Common causes
Irritable bowel syndrome (IBS)
Peptic ulcer disease
Diverticulitis
Chronic pancreatitis
Hepatitis
Cholecystitis
Pelvic inflammatory disease
Vascular insufficiency

Chronic Abdominal Pain

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Appendicitis
Inflammation of the appendix
Periumbilical pain that eventually shifts to the RLQ, N&V, slight fever
Rovsing sign, Blumberg sign
Complications include perforation, peritonitis and abscess

Inflammatory Disorders

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DiIAGNOSTICS:
History, Physical
WBC
U/A
CT, U/S

Inflammatory Disorders

TREATMENT:
Appendectomy
Antibiotics
Parental fluids

Inflammatory Disorders

Localized or generalized inflammatory process
Acute or chronic
Trauma or rupture
Primary or Secondary
Abdominal pain is the most common symptom
Rebound tenderness, muscular rigidity, spasms
Abdominal distention, ascites, fever, tachycardia, tachypnea, N&V, altered bowel habits.
Complications include hypovolemic shock, septicemia, intra=abdominal abscess formation, paralytic ileus and organ failure

Peritonitis

DIAGNOSIS
CBC
Peritoneal aspiration
X-ray
U/S, CT Scan

Peritonitis

TREATMENT
Antibiotics
NG suction
Analgesics
IV fluids

Peritonitis

An inflammation of the mucosa of the stomach and the small intestine
Clinical manifestations include nausea, vomiting, diarrhea, abdominal cramping, and distension.
Fever, increased white blood cells (WBCs), and blood or mucus in the stool may be present.

Gastro-enteritis

An autoimmune disease that includes Crohn’s disease and ulcerative colitis (UCI)
Characterised by idiopathic inflammation and ulceration.
Multiple factors are involved in the etiology of IBD (environmental factors, genetics, immune function)
Commonly occur during the teenage years and early adulthood and have a second peak from ages 50 – 70.
Unpredictable periods of remission interspersed with episodes of acute inflammation
Debilitating.

IBS

Can affect any area of the GI tract
Systemic autoimmune disorder
All layers of the bowel walls
Diarrhea and ABD pain
Discontinuous skip lesions
Deep ulcerations with thickening of the bowel
Cobblestoning of mucosa
Can have malabsorption and nutritional deficiencies
May have severe weight loss
Electrolyte imbalances

Crohn’s

Rectum and the colon
Inflammation is diffuse
Involves the mucosa and submucosa.
Spreads proximally in a continuous fashion.
Crypts of Lieberkuhn develop abscesses
Bloody diarrhea and ABD Pain
Complications include hemorrhage, perforations, toxic megacolon
Increased risk of colorectal cancer
Extraintestinal manifestations

Ulcerative Colitis

Ulcers forming & wounds – scar tissue replaces (area can become thickened. Granulation tissue (makes it thicker & shorter area) – less surface area
Major symptom – bloody diarrhea (many times) 10-30
Dehydration, can lose weight, absorption problems, ulcers – risk of perforations, toxic megacolon (bigger, not effective)
Most common complications:
Bleeding, inflammation, megacolon
Megacolon complication – perforation
Increased risk of colorectal cancer –need to be monitored, regular scopes
Diet
- Iron supplements, rich diet due to poor absorption, high calories
Systemic manifestations – mostly related to malabsorption, extra supplements, electrolyte imbalances need to be fixed, lactose free diet

Ulcerative Colitis

Happens from mouth to anus
Systemic autoimmune, associated w a gene
Normal and abnormal areas in GI
Mucosal edema – looks like cobblestone
Cramping, tenderness, distension, fever, fatigue
Systemic – can have arthritis due to the immune system & malabsorption, clubbing can occur (vascular changes)
Chronic findings are not a priority finding – e.g. clubbing
Lots of weight loss
Peritonitis is not uncommon
Dairy free diet
Low residue roughage and fat
Surgery is used in patients with severe symptoms that are unresponsive to therapy and in those with life-threatening complications – surgery is NOT curative in this condition.
Malnutrition is a big reason for surgery
Fistulas
Carconoma

Crohn’s

In the older client with UC, the distal colon is usually involved (proctitis).
In the older client with Crohn’s disease, the colon rather than the small intestine tends to be involved.
There is less recurrence of Crohn’s disease in older clients treated with surgical resection.
The degree of inflammation associated with both conditions tends to be less in the older adult than in the younger client.

Age-Related Considerations:Inflammatory Bowel Disease

Most common is sedentary

MALABSORPTION SYNDROME

Bacterial proliferation (parasitic infection)
Biochemical or enzyme deficiencies (lactase deficiency)
Disruption of small intestine mucosa (celiac disease, chron’s)
Disturbed lymphatic and vascular circulation (ischemia)
Surface area loss (short bowel syndrome)

MALABSORPTION SYNDROME

Can be mechanical or non-mechanical

Intestinal Obstruction

Mostly due from adhesions when in the small intestine
Large intestine often due to carcinoma, volvulus and diverticular disease
Pain comes and goes in waves

mechanical Intestinal Obstruction

Occurs from neuro-muscular or vascular disorder
Most common is a paralytic ilieus.
Constant generalized pain
Strangulated is severe

Non-mechanical Intestinal Obstruction

________ – happens because of blockage, air that you swallow – can’t go anywhere, fluid, gas, everything backed up proximal to that obstruction
Pain
Nausea and vomiting
High pitched bowel sounds * or no bowel sounds

Distension

_______ causes electrolyte imbalance due to impaired absorption

Obstruction

Risk factors for _______
Alcohol
Inactivity
IBD
FAP
Age >50
Family history
Obesity
Polyps
Smoking
Diet high in red meat

colorectal cancer

Second most common cause of cancer death in Canada
Highest location of ___________ are in the rectum
Adenocarcinoma is the most common type

colorectal cancers

_____ needs to be pink – white is bad (no circulation, high risk gangrene)

Ostomy

_______ are outpouchings of the colon. When they become inflamed, the condition is diverticulitis. The inflammatory process can spread to the surrounding area in the intestine.

Diverticula

________ – lots of pouches happening, most people are asymptomatic, sigmoid colon
Diverticulitis – inflammation

Diverticulosis

_____ comes first then _____

Diverticulosis; diverticulitis

Often asymptomatic as there is no inflammation only the presence of diverticula
Alternating constipation with diarrhea
High fiber diet

Diverticulosis

Diverticula are inflamed
Fecaliths
Abdominal pain over the involved area.
Tender LLQ mass can be felt on palpation
Fever/chills, N&V, increased WBC (except with the elderly who may be asymptomatic)
When acute – NPO to rest colon.

Diverticulitis

Hemorrhoids
Anal fissure
Anorectal abscess
Anal fistula
Pilonidal sinus

anorectal problems

________ – increase bilirubin BEFORE it gets to the liver
- RBC breaking down too much, too much for liver to deal with

Prehepatic jaundice

Post hepatic (cholestatic) jaundice – cannot reach duodenum, find poop color changes to white (clay coloured)

Hepatic jaundice

_____ – water soluble, secreted into the bile, out thru small intestine, large intestine converts it to something else (gives it to brown colour), stercobilinogen, converted into urobilonogen which goes back to body or something – becomes important when checking lab work

Direct

______ – not water soluble

Indirect

Any type of change to liver, inflammation to liver

hepatitis

Most common – viral
Rubella virus can do this, herpes
ABCDE – most common virus

hepatitis

Impaired bile flow
Important: liver cells can regenerate, no other complications or something
Liver cell damage – liver cell necrosis happens, but you can regenerate that liver
Chronic problem, chronic inflammation – scar tissue, fibrosis, cells won’t work the same
Early phases – muscle discomfort, rash, malaise
Acute – jaundice, peritus (itchy)

hepatitis

antibody to this virus, show up as immunoglobulin G, show up as acute hepatitis
anorexia, nausea vomiting, jaundice, last 4-6 weeks (15-50 days)
Fecal and oral transmission

Past response/response from vaccination – you get immunoglobulin effect IG-G; lifelong immunity w that one

Hepatitis A

can live outside the body for 7 days
Needle stick injury can cause this
Can be spread from mum to baby, IV drug use, sexually transmitted infection as well
IG-M – acute infection. But sub named according to the type of hepatitis
Chronic infection >6m HPSAG (I think?) – causes more inflammation of the liver, try and prevent any kind of complications & progression
– at risk for cancer, hepatocellular cancer
Decrease the viral load
Minimize symptoms and progression – drugs will decrease HBV virus but not get rid of it
Acute – not much treatment, symptom management

Hepatitis B

Spread IV drug use, sharing contaminated needles
Used to be seen w blood transfusions
Linked to high risk sex behaviours, perinatal
Causes a lot of long term liver damage
Antibodies to HCV does not indicate immunity – have to test differently, find out if it’s active or not
Assess the viral load
Chronic lifelong, lifelong fatigue
Long term inflammation, you have scarring, the cirrhosis

Hepatitis C

needs hepatitis B to survive

Hepatitis D

no access clean drinking water

Hepatitis E

Alcohol & drug induced hepatitis – acute and chronic liver problems w this the same way
Elevated liver enzymes
AST and ALT - if levels don’t go down liver failure and liver death
Drug induced liver injury – can be related to OTC drugs (Tylenol – most common)
No more than 4 grams

Hepatitis

Autoimmune problems – _____ cells attacking itself

liver

Any liver damage – risk of liver _____

cancer

Incubation period: 15-50 days
Route of transmission: fecal, oral

HAV

Incubation period: 45-180 days
Route of transmission: alcohol and drug induced

HBV

Incubation period: 14-180 days
Route of transmission: parenteral, sex, perinatal

HCV

Incubation period: 2-26 weeks
Route of transmission: needs HBV

HDV

Incubation period: 16-64 days
Route of transmission: fecal oral

HEV

Liver enzymes & LFTS are checked

Liver problems

liver cell injury, you will see elevated AST & ALT; if you have bile duct injury, might see increase ALP & GGT

Liver enzymes

serum albumin, serum bilirubin and INR (decreased albumin, increased bilirubin)

What reflects more damage

Anti-HAV IGM (acute infection)
Anti-HAV IgG (long term immunity is present)

HAV diagnostic studies

HBsAg (infection)
HbeAg (high virus activity and high infectiousness)
Anti-Hbe (less infectious state)
Anti-HBc (acute infection)
Anti-HBs (protective antibody)

HBV diagnostic studies

Anti-HCV (initial screening test for HCV. Can be past exposure of current infection)
HCV RNA (ongoing viral multiplication)

HCV diagnostic studies

DRUG THERAPY
Directed at eradicating the virus
Support Therapy
Antiemetics
Drug therapy for chronic hepatitis B
Focused on
Decreased viral load
Decreased liver enzyme levels
Decreased rate of disease progression
Decreased rate of drug-resistant HBV

Hepatitis

Hepatitis A vaccine
Immunoglobulin (IG)

Hepatitis A prevention

Immunization
Hepatitis B immunoglobulin (HBIG)

Hep B prevention

No Vaccine to prevent HCV

Hep C prevention (none)

An umbrella term for a range of liver conditions that affect people who drink little to no alcohol
There is to much fat stored in the liver.

Nonalcoholic fatty liver disease (NAFLD)

Severe liver disease with inflammation and can lead to scarring (cirrhosis)

Nonalcoholic steatohepatitis (NASH)

Alcohol consumption is a frequent cause of both acute and chronic liver disease.
Acute alcoholic hepatitis is a syndrome of enlarged liver (hepatomegaly), jaundice, elevation in liver enzyme tests (AST, ALT, alkaline phosphate), low-grade fever, and possibly ascites and prolonged prothrombin time.
Drug-induced liver injury (most common: acetaminophen)

Alcohol/drug induced hepatitis

Chronic inflammatory disorder
Immune system attacks its own liver cells

Autoimmune hepatitis

Autosomal recessive gene disorder of copper metabolism
Increased copper storage
Hallmark is corneal Kayser-Fleisher rings

Wilson’s disease

Genetic disorder causing an increase and inappropriate iron absorption

Hereditary hemochromatosis

Chronic and slowly progressive inflammatory disease
T cell mediated attack on the small bile duct epithelial cells

Primary biliary cirrhosis

Compensated or decompensated
Onset usually insidious
Compensated
Abdominal pain
Lassitude
Fatigue
Weight loss
Enlargement of liver and spleen
Decompensated
Anorexia
Dyspepsia
Nausea/vomiting
Weakness, muscle loss
Change in bowel habits

Early manifestations of cirrhosis

Two causative mechanisms
Liver failure
Portal hypertension

Late manifestations of cirrhosis

Acute
Gallstones and alcohol are the most common causes.
Autodigestion
Mild symptoms to necrotizing
Predominant symptom is ABD pain.
Pseudocyst and abscess are complications

Pancreatitis

Primary test is serum amylase and lipase
Primarily supportive care (hydration, managing electrolytes, pain control and minimizing pancreatic stimulation.

Pancreatitis

GOALS
Relief pain
Prevent or alleviate shock
Reduce pancreatic secretions
Control fluid and electrolytes
Removal of precipitating cause

Pancreatitis

Abdominal pain
May have episodes of acute pain but usually chronic increasing in intensity
Heavy, gnawing felling
Pain not relieved with food or antacids
Symptoms of pancreatic insufficiency

Chronic pancreatitis

Mild leukocytosis
Increased sedimentation rate
Normal or abnormal amylase and lipase
Fecal fat in the stool
Vitamin deficiencies
Glucose intolerance
ERCP, CT, MRI, MRCP

Chronic pancreatitis

Focus on relieving pain and controlling pancreatic exocrine and endocrine insufficiency.
Diet,
Pancreatic enzyme replacement
Diabetes control
NO alcohol
Stop smoking
Pancreatic enzyme products (pancreatin and pancrelipase)

Chronic pancreatitis

Seen w people who drink a lot
Smoking increases problems
Increased fat in the stool

Chronic pancreatitis

most common disorder of the biliary tract.
Stones in the gallbladder
Can cause obstruction
High cholesterol precipitates

Cholelithiasis

Inflammation of the gallbladder
Acute or chronic
Usually associated with cholelithiasis

Cholecystitis

Incidence of ______ increases w age
Liver volume decreases, drug metabolism slows, and hepatobiliary function is altered.
The ability of the liver to respond to injury, particularly to regenerate after injury, is decreased.
Transplanted livers take longer to regenerate in older adults than in younger adults.

Liver disease

Older clients are particularly vulnerable to drug-induced _____.

hepatitis

excretion of waste, filter

Kidney

the basic structural and functional unit of the kidney

Nephron

controls the diuretic hormones, fluid stuff/balance, blood pressure, activation of vitamin D

Renin system

forming red blood cells

Erythropoietin

Primary function – filtering waste, maintaining fluid and electrolyte balance, excretion
Secondary function – monitoring BP, sudden onset hypertension is often related to the kidneys

Kidneys

Decrease in size and weight of kidney from 30 to 90 years of age
Decreased blood flow
Physiological changes to kidney, bladder, and urethra

Age related considerations

Size and weight of kidneys – what does that mean to older people?Can’t ____ the same way
Medications can’t be filtered the same way
Weakening of muscles
Bladder volume is less
Weakening elasticity – can strengthen through exercise

filter

Bathroom routines can be helpful
Fluid intake is important but stop a specific time before bed – incontinence in the night

Older adults

What colour is urine?
Does it hurt when you pee (dysuria)?
How often do you need to pee? Do you feel that you’ve been able to expel all of it?
Weight gain/loss?
Input/output?
What medications are you on? Medications that change urination?
Do you leak urine? Are you having any incontinence?
Do you have any abdominal discomfort?

Subjective data

Anticholinergics can impact urination?
Antihistamines, anti-osmotics can impact urinary system
Lower back injury?
How long has this been going on?
Past UTIs, how were they treated? What kind of infection?
Pregnancy? Was it traumatic (tears, pelvic area problems after)?
Surgeries? Scar tissues in pelvic area – can impact elasticity and bladder doesn’t respond the same way.
Edema? Weight gain? Fluid stuff – related to kidney stuff.

Subjective data

Toxicity stuff:
Smoking? Chemical exposure?

Urinary system subjective data

Do you need to urinate in the middle of the night to urinate? (_______)

nocturia

Back pain?
Have you ever had a kidney infection? Stones?
Diet
Surgeries
Family history of polycystic kidney disease (multiple cysts growing, takes over functioning of kidneys)
Urinalysis – test
Ultrasound
CT scan – anything to visualize the kidneys, dye up ureters to see
Labs – urea and creatin tell you about function of the bladder

Kidneys

not able to release, not able to send message to person that it is emptying completely. May need catheter for life if medications don’t work.

Neurogenic bladder

Urinalysis – should be tested within 1 hour or refrigerated
Specific gravity 1.005 – 1.030
PH 4.6 – 8.0
C&S
protein

URINE tests

WBC
RBS
CR, BUN (urea), HCO3, ca, K, phosphorous, uric acid, Na
Urea to cr ratio
Glomerular filtration rate

Lab tests

Don’t forget specific gravity
- Tells us the ____ of urine

concentration

tells us about the FUNCTION of the kidneys

Glomerular filtration rate

urine culture and sensitivity? The urine culture test is performed to grow and identify organisms, mainly bacteria and fungi that may cause a Urinary Tract Infection (UTI).

C&S

_______ are excreting a huge amount of the body’s potassium
Phosphorus – elevated in renal disease
Normal sodium level – 135-145
When lower person will have symptoms of being lethargic

Kidneys

_____ in general will be completely altered when someone is having problems w their kidneys

Electrolytes

Infection signs: fever, chills
Balance of water: thirst, dehydration symptoms
Flank & groin discomfort & suprapubic area
Overactive bladder – people will feel instantly that they have to urinate

Urinary infection

Urine tests
Blood tests
Radiological procedures
Renal radionuclide imaging
Surgical study (renal biopsy)
Endoscopy
Urodynamic testing

Diagnostic studies

Urinary tract infection
Acute pyelonephritis
Chronic pyelonephritis
Urethritis
Urethral diverticula
Interstitial cystitis
Renal tuberculosis

Inflammatory problems

Urine act as an antiseptic *
Bacteria washed out with voiding
Ureters function to prevent back flow
Prostate g;md secretes infection fighting substance
Normal body immune system
Antibacterial substances in mucus lining of bladder
Lactobacilli in normal vagina cause increased PH

Defence system against bacteria

Urinary system has it’s own _______ system *
Ureters prevent backflow – you will get kidney infection w backflow
Mucus within bladder is antibacterial
If any of these things fail, the risk of infection is great

defense

Who is at risk of __________? Women shorter urethra. People with catheters are at increased risk. Older people, immunocompromised, Benign prostatic hyperplasia (BPH), prolapsed bladder, kidney problems in general, people who are in hospital. **

urinary tract infection

Include cystitis, urethritis, pyelonephritis
E.Coli is the most common pathogen
Predisposing factors include tumours, stones, urinary retention, foreign bodies functional disorders and factors compromising immune response

Urinary tract infection

Inflammation of the urethra

Urethritis

Inflammation of the urinary bladder
Characterized by pain, urgency, frequency, hematuria

Cystitis

Inflammation of the renal parenchyma and the collecting system usually caused by infection.

Pyelonephritis

is the leading cause of UTI

E.Coli

____ has these 3 areas
Urethritis – often seen w STIs. *
Cystitis – bladder infection.
Pyelonephritis – inflammation of kidneys.

UTI

______ & _______ – sudden onset for pain, STI one of main causes. Kidney stones can also cause this. Strictures, tumours, any growth. Problems w immune system. Diabetes w high glucose (bacteria loves sugar), lots of sugar in bladder.
Cloudy urine – pyuria WBC showing up in urine

Urethritis & Cystitis

Can be classified as:
Upper or lower urinary tract infection
Initial or recurrent
Complicated or uncomplicated
Unresolved bacteriuria or bacterial persistence

UTIs

upper UTI
If UTI is not treated – complications: kidney damage, chronic kidney damage, lose kidney function leading to further renal disease

Pyelonephritis

urge incontinence can be a complication

Chronic UTIs

becomes an issue diet, can lead to chronic pyelonephritis – can cause kidney to shrink & not be as functional

Chronic kidney stones

Initial UTI, recurrent UTI, complicated UTI (gone someplace else), resistant to medications, complicated

Classifications of UTIs

Most common cause I bacterial infection, but fungi, protozoa or viruses can infect the kidney.
Symptoms include, chills, malaise, fever, flank pain, vomiting and symptoms of lower urinary tract infections.
Antibiotic either inpatient or outpatient depending on the severity.
Can lead to urosepsis, shock and death of undiagnosed and untreated.

Acute Pyelonephritis

Inflammation – susceptible to infection in little pockets, causing abscesses

Pyelonephritis

Acute – stricture & backflow, urine not completely emptying, infection that travels upwards, kidney stones, symptom: people feeling like they have the flu (nausea, vomiting, fever, chill, malaise, tenderness)

Acute Pyelonephritis

lab work is monitored to see kidney function, regular kidney tissue is damaged will be replaced by scar tissue

Chronic Pyelonephritis

A term used to describe a kidney that has become shrunken and has lost function owing to scarring or fibrosis.
It usually occurs as the outcome of recurring infections involving the upper urinary tract
Can lead to end stage renal disease of both kidneys are involved.

Chronic Pyelonephritis

sepsis caused by infections of the urinary tract, including cystitis, or lower urinary tract and bladder infections, and pyelonephritis, or upper urinary tract and kidney infections. Will eventually go into shock if untreated.

Urosepsis

Inflammation of the urethra
Causes
Bacterial or viral infection
Trichomonas and monilial infection (especially in women)
Chlamydia
Gonorrhea (especially in men)

Urethritis

The result of obstruction and subsequent rupture of the periurethral glands into the urethral lumen with epithelialization (regrowth of tissue) over the opening of the resulting periurethral cavity
More common in women than in men
They occur mostly in the area of the periurethral glands

Urethra diverticula

Chronic, painful inflammatory disease of the bladder
Characterized by symptoms of urgency, frequency, and pain
Bladder pain syndrome or painful bladder syndrome
Assessment focuses on characterization of the pain associated with interstitial cystitis.
Data collection includes a bladder log or voiding diary kept over a period of at least 3 days to determine diurnal voiding frequency and patterns of nocturia.

Interstitial cystitis

Rarely a primary lesion
It is usually secondary to TB of the lung.
In a small percentage of clients with pulmonary TB, the tubercle bacilli reach the kidneys via the bloodstream.
Onset occurs 5–8 years after the primary infection.

Renal TB

Glomerulonephritis
Acute post-streptococcal glomerulonephritis
Goodpasture’s syndrome
Rapidly progressive glomerulonephritis
Chronic glomerulonephritis
Nephrotic syndrome

IMMUNOLOGICAL DISORDERS OF THE KIDNEYS

An immune related inflammation of the glomeruli.
Proteinuria, hematuria, decreased urine production and edema.
Elevated serum urea and creatinine can be present.
Wbc, rbs and cast are present in the urine.

glomerulonephritis

Most common in children and young adults - but all age groups can be affected
Occurs 5 – 21 days after an infection of the pharynx or skin by nephrotoxic strains of GrouP A B-hemolitic streptococci.
Generalized body edema, hypertension, oliguria, hematuria and proteinuria.
Treatments consists of managing the symptoms – diuretics, antihypertensives, diet changes, REST

Acute Poststreptococcal Glomerulonephritis

Is an autoimmune disease characterized by circulating antibodies against glomerular and alveolar basement membrane. Primary target organ is the kidney, but the lungs are also involved
Rare disease that is seen mostly in young male smokers
Circulating antiGBM antibodies are diagnostic of this syndrome.

Goodpasture’s syndrome

Glomerular disease associated with rapid, progressive loss of renal function over days to weeks
Renal failure may occur within weeks to months, in contrast to chronic glomerulonephritis, in which it develops insidiously and progresses over many years.
Clinical manifestations include hypertension, edema, proteinuria, hematuria and RBC casts.

RAPIDY PROGRESSIVE GLOMERULONEPHRITIS

A syndrome that reflects the end stage of glomerular inflammatory disease
Most types of glomerulonephritis and nephrotic syndrome can eventually lead to _______

Chronic glomerulonephritis

Describes a clinical course that can be associated with a number of disease conditions.
Occurs when the glomerulus is excessively permeable to plasma protein - proteinuria – which leads to low plasma albumin and tissue edema

Nephrotic syndrome

Includes any anatomical or functional condition that blocks or impedes the flow of urine.
Congenital or acquired.
Causes are either intrinsic, extrinsic or functional.

Obstructive uropathies

Nephrolithiasis – crystals precipitate to form stones which lodge within the urinary system
Calculus – stone
Lithiasis – sone formation.
Pain, hematuria, renal colic, N&V,
Type of stone formation is affected by metabolic, dietary, genetic, climatic lifestyle and occupational influences.

Urinary tract calculi

Major categories of Stones
Calcium phosphate, calcium oxalate, uric acid, crystine struvite (magnesium-ammonium phosphate)
Diagnosis
Urinalysis, urine cultures, ultrasound, cystoscopy, CT, (inserting dye to see how it comes thru kidneys) IVP
Analysis of the stones – break up stone & assess, may be diet related then needs diet changes

Urinary tract calculi

Two approaches are used for the management of _______
1. management of the acute attack- pain management, infection n management
2. Directed at evaluation of the stone formation and the prevention of further development of stones.
Treatment –surgery, lithotripsy, diet, medications,

renal lithiasis

PLAN
Relieve pain
Relieve obstruction
Educate client on prevention.

Nursing management: renal calculi

A rise in the incidence of traumatic renal injuries is related to an increase in the mechanization and speed of transportation and to the increase in violent crimes and injuries.

Renal trauma

Nephrosclerosis
Renal artery stenosis
Renal vein thrombosis

renal vascular problems

A vascular disease of the kidney characterized by sclerosis of the small arteries and arterioles of the kidney, resulting in renal tissue destruction.
Benign nephrosclerosis
Malignant (accelerated) nephrosclerosis

Nephrosclerosis

Partial occlusion of one or both renal arteries and their major branches
A major cause of abrupt-onset hypertension

Renal Artery Stenosis

An embolus occurring in the renal vein
Symptoms include flank pain, hematuria, or fever, or nephrotic syndrome

Renal Vein Thrombosis

Polycystic kidney disease **
Medullary cystic disease
Alport’s syndrome

Hereditary Renal Diseases

Most common genetic disease in Canada
Multiple cysts are present
Enlarging cysts damage surrounding tissue
Two forms of polycystic kidney disease
Adult form – autosomal dominant disorder
Childhood form – rare autosomal recessive disorder

Polycystic Kidney Disease

A hereditary disorder that occurs in two forms:
Autosomal recessive form associated with renal failure before age 20
Autosomal dominant form associated with renal failure after age 20

Medullary cystic disease

Also known as chronic hereditary nephritis
Two forms
(1) Classic Alport’s syndrome—inherited as a sex-linked
(2) Nonclassic Alport’s syndrome—inherited as an autosomal trait

Alport’s Syndrome

causes Sensio neural problems, deafness, problems w eyes **

Alport’s

no deafness / eye stuff involved

Nonclassical Alport’s

Various metabolic and connective tissue disease processes may have an effect on renal function

Renal Involvement in Metabolic and Connective Tissue Diseases

Kidney cancer is increasing
Occur in the cortex or the pelvis
Benign or malignant
No characteristic early symptoms
Generalized symptoms include weight loss, weakness, anemia
Classic symptoms of gross hematuria, flank pain and a palpable mass are those of advanced disease.

Urinary tract tumours

6th most common type of cancer is Canadians
Most common tumor of the urinary tract is the transitional cell carcinoma of the bladder.
Symptom of gross, painless hematuria is the most common finding.

Bladder cancer

Diagnosis is done with a urinary log, urine residuals, U/A, urine cultures, ultra sounds, IV, CT Pelvic muscle strength testing, Bladder and sphincter testing.
Treatment depends on the type but can consist of bladder routines, catheterizations, muscle floor therapies, biofeedback, incontinent pads, condom catheters, electric simulation.
Drugs
Muscarinic Receptor Antagonist and Anticholinerchics
A-Adrenergic Antagonists
Tricyclic Antidepressants
Calcium channel blockers
Hormone therapy

Urinary incontinence and retention

outside urethra

Urostomy

common medication used for spasms

Ditropan

not used for bladder spasms

Opioids

Simple method of urinary diversion
Care of this tube is similar to the care of a urethral catheter.
Can be short term or long term
Ditropam or opiods for bladder spams

Supra pubic catheter

Most commonly performed
Segment of the ileum in converted

Ileal conduit

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